Partial Breast Reconstruction With Flaps

Introduction

Breast conserving therapy (BCT) with partial mastectomy followed by radiation therapy is the gold standard of early stage invasive breast cancer treatment, with an equivalent 5-year survival rate to that of mastectomy alone with stage I or II breast cancer.

Partial mastectomy includes both lumpectomy and quadrantectomy. Oncoplastic surgery, the combination of partial mastectomy with partial breast reconstruction reduces potential breast deformities and results in aesthetic breast reshaping. The first aim of oncoplastic surgery is avoiding mastectomy with complete cancer ablation and clear surgical margins without the distortion of the natural shape of the breast. The main steps of oncoplastic approach are free margin cancer ablation, optimal scar orientation, breast tissue rearrangement and, when indicated, contralateral breast reshaping in order to achieve symmetry.

Indications and Contraindications

Patients often require surgery after partial mastectomy to correct volume discrepancy, contour deformity and nipple malposition. The resection of more than 15%–20% of the breast parenchyma in a small-volume (A or B cup) breast and more than 30% in larger breast will determinate volumetric deformities and bilateral asymmetries ( Fig. 15.1 ). Patients with small or non-ptotic breasts could require volume replacement. In addition, radiotherapy distorts the shape of the breast, initially causing breast edema and skin erythema and eventually causing parenchymal fibrosis, retraction, skin atrophy, hyper-/hypopigmentation, and telangiectasia. The long-term results of radiation are difficult to predict but stabilize 1–3 years after radiation. Furthermore, oncoplastic surgery extends the indications for breast conservation surgery to allow the resection of much larger tumors relative to breast size. In these patients, partial breast reconstruction with flaps could be considered as an important part of whole breast cancer treatment.

The main indication for pedicled flaps is immediate or delayed partial breast reconstruction when volume replacement is necessary. However, other conditions will require locoregional flaps in partial breast reconstruction. These flaps can be utilized as a salvage procedure after partial/total previous free flap loss for breast reconstruction. They can be combined with implants in breast reconstruction as well.

Previous axillary or thoracic surgery with damage to the thoracodorsal vessels is a contraindication for latissimus dorsi flap or thoracodorsal artery perforator (TDAP) flap; these patients may be candidates for a lateral intercostal artery perforator (LICAP) flap. Previous scars and irradiation to the area may also result in the limitation of local pedicled perforator flaps ( Fig. 15.2 ). However, when breast deformity after partial mastectomy and radiotherapy is severe, the optimal choice is to perform a complete mastectomy and autologous reconstruction with a free flap transfer.

Preoperative Evaluation and Special Considerations

Preoperative evaluation of the patient must be standardized and detailed. Any previous breast surgery should be taken into account when planning BCT. Different body types, skin laxity and fat distribution are important factors in the decision-making process. Breast physical examination must include the evaluation of breast skin elasticity and thickness, scars and any defining marks such as tattoos, stretch marks and contour irregularities. Breast shape, grade of ptosis, and size are determinants of success in surgical treatment. The base and width of the breast, the width of the nipple–areola complex (NAC), the height of the nipple and the distance from the sternal notch, midline and inframammary fold must be recorded in detail. Any natural breast asymmetry should be pointed out to the patient before surgery. Furthermore, palpation for masses or abnormalities in the breast parenchyma, nipple examination and detailed documentation of breast sensation are mandatory.

In planning the approach to treat the partial mastectomy defect, the primary decision that must be made is whether reconstructive surgery will be needed after the tumor excision. Poor cosmetic outcomes after partial mastectomies can occur from both the amount of breast tissue removed and/or the site of the cancer. Partial breast reconstruction with flaps depends on the size of the tumor, its anatomical location, and the amount of tissue resection required to achieve free margins in relation to the volume of the breast.

There are two basic types of surgical techniques in partial breast reconstruction: volume displacement and volume replacement techniques. Volume replacement techniques are the focus of this chapter. They are used in small to moderate-sized breasts or when the tumor/breast ratio is large and the residual breast tissue is insufficient for the reshaping and the replacement of the defect. Volume replacement is performed with non-breast local or distant flaps offering both tissue for the filling of the glandular defect and the skin deficiency of the reconstructed breast.

When volume replacement is necessary, the decision of which technique will be used is determined mostly by the surgeon's experience and the size of the defect in relation to the size of the remaining breast. The non-breast locoregional flaps offer extra tissue required in large tumor excisions/quadrantectomies for the replacement of the breast volume, however they can be more demanding procedures and associated with donor-site and flap morbidity. Small lateral defects can be easily repaired with skin rotation flaps or lateral thoracic axial flaps. However, most of these fasciocutaneous flaps may be unavailable in patients who have had axillary lymph node dissection. The latissimus dorsi muscle (LD) or musculocutaneous flaps have been very popular as a method of choice in partial breast reconstruction. On the other hand, local pedicled perforator flaps have allowed surgeons to replace large defects with the minimum donor-site morbidity. Fasciocutaneous perforator flaps offer sufficient soft tissue coverage while sparing the muscle and tend to have a lower seroma rate.

Surgical Techniques